Derm Cases · Dermatology / Psychodermatology
OSCE — irregular scalp alopecia: diagnose trichotillomania, use trichoscopy language, and plan behavioural care
An 8-minute OSCE on recognising trichotillomania, differentiating alopecia areata and tinea, listing trichoscopic signs, starting habit reversal referral, and warning about trichobezoar if trichophagia is present.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE on recognising trichotillomania, differentiating alopecia areata and tinea, listing trichoscopic signs, starting habit reversal referral, and warning about trichobezoar if trichophagia is present.
Brief (to candidate)
A 14-year-old has an irregular crown patch of hair loss with multi-length residual hairs and no scale. She quietly reports stress-related pulling and occasional chewing of hair. You have 8 minutes to diagnose trichotillomania, exclude key mimics, outline trichoscopy, and plan management including safety netting for trichophagia.
[2]Candidate instructions
- State the likely diagnosis and supporting signs.
- Contrast with alopecia areata and tinea capitis.
- Name at least three trichoscopic features of TTM.
- Outline first-line behavioural therapy and when drugs (e.g. adult NAC context) may be considered.
- Safety-net abdominal symptoms of trichobezoar.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Irregular multi-length non-scarring alopecia + pulling history = TTM[1] |
| Mimics | AA smooth/exclamation; tinea scale/KOH |
| Trichoscopy | Flame hairs, V-sign, hair powder (± tulip/hook)[2] |
| Therapy | HRT/behavioural first; SRIs weak alone; adult NAC evidence context[3][4] |
| Emergency | Trichophagia → trichobezoar/Rapunzel warning[5] |
| Communication | Non-judgemental, shame-sensitive |
Model key actions
- Do not start systemic steroids for “areata” without trichoscopy correlation.
- Refer early to psychology skilled in BFRBs.
- Ask specifically about swallowing hair and GI symptoms.
Common errors
- Labelling all patchy loss as alopecia areata.
- Offering SSRI as sole therapy.
- Missing trichophagia history.
References5ShowHide
- [1]Hautmann G, Hercogova J, Lotti T. Trichotillomania. JAAD, 2002.PMID 12063477
- [2]Rakowska A, et al. New trichoscopy findings in trichotillomania. Acta Derm Venereol, 2014.PMID 24096547
- [3]Grant JE, et al. N-acetylcysteine, a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry, 2009.PMID 19581567
- [4]McGuire JF, et al. Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. J Psychiatr Res, 2014.PMID 25108618
- [5]Balawender K, et al. Trichopsychodermatology: trichotillomania and trichophagia leading to Rapunzel syndrome. Postepy Dermatol Alergol, 2022.PMID 36090734